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Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.102 n.3 Cape Town Mar. 2012

FROM THE EDITOR

Traditional healers formalised?

Traditional healers are the first to be called for help when illness strikes the majority of South Africans. Their communities have faith in their ability to cure or alleviate conditions managed by doctors, and much more. A visit to such practitioners' websites (they are up with the latest advertising technology!) shows that they promise help with providing more power, love, security or money, protection from evil people and spirits, enhancing one's sex life with penis enlargement and vagina tightening spells, etc. Contemplating such claims, it is easy to be dismissive of traditional healers. But in this issue of the SAMJ Nompumelelo Mbatha and colleagues1 argue that the traditional healers' regulatory council, promised by an Act of Parliament, should be established, followed by (or preferably preceded by) formal recognition by employers of sick certificates issued by traditional healers. Can matters be so simply resolved? What does this mean for doctors and other formally recognised healthcare professionals, and how to respond to such claims and social pressures?

Cultures and beliefs

The fact that a large proportion of the population believes in and follows traditional cultural activities confirms that they are a much-valued component of people's life experiences. They are part of peoples' significant truths that occupy the brain's limbic system (or primitive brain) where our fears, feelings, beliefs, and the four Fs of human evolutionary survival (food, fight, flight and fertility) are situated. However, long survival and large numbers of adherents of such practices does not validate them. Medicine believed in the four humours for centuries, and apartheid was made no less evil by most (white) voters at the time voting for it. Our thinking (cognitive) brain situated in the cortex responds more slowly, and its conclusions may not necessarily concur with the deep-seated and difficult-to-shift beliefs in our primitive brains.

In 2010 the Treatment Action Campaign (TAC), honoured for its brave activist role in reversing AIDS denialism in government in South Africa, launched a protest against a television programme that screened the 'Christ Embassy Healing School' claims that they could faith-heal cancer, heart disease and arthritis. Their action was prompted by at least two people dying after attending Christ Embassy 'healing' services and 'faithfully' stopping their ARV treatment, one of them also infecting family members with multidrug-resistant TB.2

Faith in religions or cultural healers shares powerful influences on the way in which humans are primed by nature or nurture to respond. Religions and cultural beliefs may also share rituals that are similar, e.g. circumcision is practised as a rite of passage for religious or cultural reasons.

Another council?

South Africa already has several councils for healthcare personnel, namely the Health Professions Council (doctors, dentists and related professions - physiotherapy, psychology, etc.), the Nursing Council, the Pharmacy Council, the Dental Technicians Council, and the Allied Health Professions Council (Homeopathy, Chiropractic, Naturopathy, Chinese Medicine and Acupuncture, etc.) To add to these the Traditional Healers Bill3 intends that a Traditional Healers Council be established to oversee the registration and regulation of the practice of the following categories of traditional healer: Inyanga (herbalist or traditional doctor), Sangoma (diviner), Ababelekisi (traditional birth attendants) and Ingcibi (traditional surgeons).4

However, the Medicines and Related Substances Control Act (Act 101 of 1965) does not adequately provide for the regulation, registration and control of complementary medicines and African traditional medicines. It is more appropriate for the regulation of allopathic medicines. Most complementary medicines do not readily meet the requirements of the current medicine registration system.4

How is it possible for such a diversity and often conflicting range of systems and views to be accommodated sensibly, peacefully and to the benefit of South Africa's people?

Understanding truths

As a starting point I draw from the insights of William Gardner,5 who described the four main domains of truth: rhetorica (debate), mystica (beliefs, religion), logica (reason), and empirica (research). He suggests that the terms opinion, belief, proof and fact should be reserved for their respective domains. The tests of truth often differ among the domains and cannot be honestly reconciled, only accepted. For the purposes of this topic we consider three domains of truth.

The views of rhetorica have been acquired through persuasion and debate. These are typically arrived at and formalised by human institutions such as parliament, the law courts and journalism. The Government Gazette3 that proposes a regulatory council for traditional healers is an example of the outcome of rhetorical debate by parliament.

In the domain of mystica, truths are derived from beliefs and are not shaped by research findings, nor need they be altered to conform to such findings. This is where the religions of the world reside. An example of a health system based on belief is homeopathy, expounded by Hahnemann in 1810 but the truths of which contradict known laws of physics and chemistry. The truths of the other groups in the Allied Health Professions Council, and of traditional healers, also largely reside in the domain of mystica. One should add that the early history of medicine was largely influenced by beliefs. Traditional healers' strong belief in the continuing influence of ancestors is similar to the notion of spiritual beings (saints and angels) of many religions of the world.

Medicine and the other professions in the Health Professions Council, Nursing and Pharmacy, occupy the domain of empirica. In empirical field studies, correlational studies and experiments were devised to test and establish the truth of different types of empirical events and relationships. One of the reasons for medical opinions often being experienced as less convincing than those of systems based in the domain of beliefs (who claim knowledge of the absolute truth) is that scientific research cannot prove the truth of an assertion of fact - it can only support the assertion. A scientific theory must be testable and to be accepted as true, must pass the test.

Regulating beliefs

Humans have an infinite capacity for beliefs. But should beliefs be regulated, and if so how?

The major religions in South Africa are not regulated by government councils, as is being attempted for traditional healers, who claim to practise in the healing professions but whose truths occupy the domain of beliefs. Furthermore, as we have seen, the remedies provided by the belief systems, including traditional healers, cannot meet the requirements of the current medical registration system.

It is therefore only when such beliefs or agencies cause harm that action may be taken. But facts established by empirica may clash with the truths of other domains, and these may be hard to shift. For instance, Professor Peter Folb, then Chairman of the Medicines Control Council, was removed from this office by beliefs, strengthened by the rhetoric of senior politicians and promises of a share in profits of the sale of a toxic solvent that was touted as being able to cure AIDS. Another serious blot on South Africa's healthcare was the AIDS denialist belief of President Mbeki and the actions of his health minister, Dr Manto Shabala-Msimang. By courage and persistence the TAC led the way via the courts to overcome the government's harmful denialist HIV/AIDS policies and to commence treating those in need - similarly their campaign against harmful faith-healing claims. Another paper in this issue6 draws attention to the potential harms of traditional medicines, whose vast variety and variability of ingredients makes registration of such substances well-nigh impossible. And how does one regulate communication with ancestors? The Advertising Standards Authority of South Africa recognises the susceptibility and vulnerability of humans and disallows false and unsubstantiated claims. But the publishing industry often ignores this for dubious 'health' products because of the lure of advertising revenue in this flourishing market.

Joining forces?

Medicine has evolved from a system that historically was largely based on beliefs and often was harmful. At the time Hahnemann's homeopathic principles that provided cures so dilute that they can do little harm was often preferable to medical treatments that included bleeding to get rid of bad humours, starvation to prevent new ones from forming, and purging to get rid of the rest, from above, from below, or from any other exit. But the facts discovered by research have transformed medicine dramatically, particularly over the past century - an evolution from mystica to empirica. Such change is not possible for homeopathy, chiropractic and other systems based on beliefs, as their limited principles must be shored up in order to survive - if they are challenged by empirica and found lacking, nothing is left but belief. On the other hand, medicine constantly challenges its truths in order to discover and acknowledge its mistakes. Given the gulf between the systems, where do traditional healers fit into the scheme of things?

There are similarities between traditional healers and the early history of medicine. Their use of a wide variety of products found in nature applied to early medical practice, and all societies have their favourite home remedies. Like medicine, their scope of practice is also wide-ranging including providing medicine, counselling and physical activities such as birth attendant and circumcision (unlike those in the Allied Health Professions Council, despite their common claim of being 'holistic'). Vera Buhrmann, a renowned psychiatrist who received an honorary doctorate from the University of Cape Town, found that the counselling traditional healers functioned in a similar way to Jungian psychoanalysts.

Traditional healers can play an important role in dealing with South Africa's health problems. A good example is the Valley Trust7 in KwaZulu-Natal, whose stance at first was non-interference in the affairs of traditional practitioners. In 1980 several of these practitioners volunteered to be part of the new Community Health Worker (CHW) or Community Based Health Education (CBHE) programme. This started a much closer association between the Valley Trust and traditional healers. Volunteer CHWs completed a community-based, experiential training curriculum for about 3 years, successful candidates receiving certification as qualified CHWs. Through constructive engagement, a good relationship between the two systems of practice was fostered in their area, where access to healthcare was a problem. Traditional healers are actively involved in activities such as a TB control programme, dispensing oral rehydration fluid, warning against re-using razor blades, social plant use programmes, nutritional programmes and dispensing condoms, and are part of student training programmes. Another example is the AIDS Foundation of South Africa, which supports HIV and AIDS education for traditional healers and recognises that they are well placed to educate people and provide counselling.8 The City of Cape Town has had traditional healers trained as TB/HIVAIDS treatment supporters.4

Medicine has a tradition of adopting and refining successful natural remedies such as the anti-malarial quinine, the medicinal properties of which were discovered centuries ago by South American Indians. Artemisinin derivatives, currently the mainstay for treatment of malaria, were originally isolated from a herb described in Chinese traditional medicine. Although claims for some traditional medicinal products in terms of safety and efficacy have been validated scientifically, enthusiasm for the perceived benefits should be tempered by reality. Of 134 plants used by traditional healers in South Africa to treat malaria studied by the UCT Department of Pharmacology, some showed early promise9 but none is close to mainstream medical adoption.

Establishing a council for traditional healers may not be sensible and could face insurmountable problems. However, acceptance and respect for their respective domains of truth has enabled health professionals to collaborate successfully with traditional healers to address some of South Africa's major health challenges.